Health History Intake Form - Cascade Internal Medicine Specialists Page 2
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4Habits:
Alcohol: □ None □ Yes: How many drinks/day ______frequency/week _______What kind________
Tobacco: □ None □ Yes: Chew or smoke?________ How many/day ______ since________________
Caffeine: □ None □ Yes: What kind___________________ How many/day ____________________
Other Recreational Drugs: □ None □ Yes: What kind_____________ How many/day _____________
Do you drive? □ Yes □ No
Do you always wear a seatbelt? □ Yes □ No
Do you exercise? □ Yes □ No
If yes, how much?____________________________________
Social History:
Work: □ Employed
□ Unemployed
□ Retired
□ Disabled
Current Occupation ____________________________Former Occupation ____________________
Marital Status: □ Married
□ Single
□ Divorced
□ Domestic Partner
Sexual preference: □ Men
□ Women
□ Both
Children (age):___________________________________________________________________
Hobbies:________________________________________________________________________
Sports:_________________________________________________________________________
Pets:___________________________________________________________________________
Other:__________________________________________________________________________
Past Surgical History (indicate date if known)
□ None
□ Bariatric surgery____________________
□ Cataracts________________________
□ Hysterectomy______________________
□ LASIK___________________________
□ Endoscopy________________________
□ Tonsillectomy______________________
□ Colonoscopy___________________
□ Thyroidectomy_____________________
□ Hernia___________________________
□ Adenoidectomy____________________
□ Spinal Surgery_____________________
□ Coronary Bypass___________________
□ Tubal Ligation_____________________
□ Cardiac Stents______________________
□ Bladder surgery____________________
□ Pacemaker________________________
□ Prostate surgery/resection_____________
□ Heart Valve________________________
□ C-Section_________________________
□ Gall Bladder_______________________
□ Orthopedic/joints___________________
□ Appendectomy_____________________
_________________________________
□ Bowel/Stomach Resection____________
□ Other_____________________________
□ Hemorrhoidectomy__________________
________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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